Kelly Culbert, right, an outreach worker, consoled a woman who had just injected heroin in the Bronx. The borough is struggling with a dramatic increase in opioid deaths.CreditPhotographs by Ryan Christopher Jones for The New York Times

The Bronx’s Quiet, Brutal War With Opioids

In the Bronx, which lost more residents to drug overdoses last year than any other New York City borough, the heroin epidemic has latched on to a vulnerable population.

Kelly Culbert, right, an outreach worker, consoled a woman who had just injected heroin in the Bronx. The borough is struggling with a dramatic increase in opioid deaths.CreditPhotographs by Ryan Christopher Jones for The New York Times

The bodies turn up in public restrooms, in parks and under bridges, skin tone ashen or shades of blue. The deceased can go undiscovered, sometimes for hours, or days if they were alone when they injected heroin and overdosed.

Terrell Jones, a longtime resident of the Bronx, was pointing to the locations where overdoses occurred as he drove through the East Tremont neighborhood, the car passing small convenience stores, rowhouses and schools.

“This is sometimes where people are being found, in their houses, dead,” said Mr. Jones, 61, looking toward a housing project along 180th Street. “Especially in the South Bronx, you have so many people in housing who overdose. To actually sit there and witness this whole thing? You’re watching this person turn all different colors. You know what I’m saying?”

The dramatic rise in opioid-related deaths has devastated communities around the United States in recent years, and has stirred concern among law enforcement and public health officials alike in New York City.

Here, the reports about the epidemic and its ravages have mostly centered on Staten Island, where the rate of deaths per person is the highest of the five boroughs. But perhaps nowhere in the city has the trajectory of opioid addiction been as complex as in the Bronx, where overdose deaths were declining until a new surge began at the turn of the decade, and where more residents are lost to overdoses than anywhere else in the city. On Bronx streets, the epidemic’s devastation is next door, down the street, all around.

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Three hundred and eight Bronx residents died of drug overdoses in 2016. That’s more than double its 2010 total of 128.

The increase in deaths — now at the highest levels since the city began collecting the data in 2000 — has been fueled by social forces that have left some Bronx residents especially vulnerable: a history of high drug use in the area; a growing supply of cheap heroin on the streets; and the proliferation of a deadly synthetic opioid, fentanyl.

Mr. Jones said he never leaves his apartment in Hunts Point without a dose of naloxone, a medication that can be used to reverse opioid overdoses. The antidote — whose brand name is Narcan — has become a necessary stopgap to prevent deaths that happen in public spaces. Mr. Jones, who has himself struggled with drug addiction in the past, now works with New York Harm Reduction Educators to help drug users.

“Regardless of how they died, it wasn’t an intentional death. Nobody woke up and said, ‘Today I want to die of an overdose,’” he said. “People have issues and reasons they’re using drugs, and it’s not for us to judge.”

In 2016, 1,374 people died from overdoses in New York City, up from 937 in 2015, according to the New York City Office of Chief Medical Examiner. The vast majority of those lethal overdoses involved opioids, a drug classification comprising prescription painkillers like Oxycodone and Percocet, morphine, and the illegal street counterpart, heroin. An additional 344 overdose deaths were reported across the city from January to March of this year, according to preliminary data made available by the New York City Health Department.

More Bronx residents died of drug overdoses in 2016 than any other New York City borough — 308. That’s more than double the number in 2010, 128. Fatal overdoses in the borough are now at their highest rates since at least 2000, as far back as official data is available. Eighty-five percent of those deaths involved opioids, and about 76 percent involved heroin or fentanyl specifically.

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Two outreach workers, Clara Cardelle and Mike Bailey, approached a man using heroin in Tremont Park in the Bronx in September.

Of the five neighborhoods with the highest opioid-related overdose rates in 2015 and 2016, four were in the Bronx — Hunts Point-Mott Haven, Crotona-Tremont, High Bridge-Morrisania and Fordham-Bronx Park — and one was in Staten Island, South Beach/Tottenville.

The crisis in the Bronx stems, at least in part, from a surge of opioids in a place where some residents have long struggled with addiction. Heroin has become much cheaper in recent years as the supply in the United States has grown, according to the Office of the Special Narcotics Prosecutor for the City of New York, and individuals with histories of drug abuse are particularly vulnerable to relapse amid a surge of cheap drugs. It has also become significantly more potent.

The cheaper, stronger heroin has been made even more dangerous by the proliferation of fentanyl, which is 50 times more powerful than heroin. Interviews with nearly 200 drug users conducted by the city health department suggest that most users are not directly seeking fentanyl; narcotics experts say the drug is likely being mixed into heroin batches, often without the dealers themselves knowing, let alone users. As effective as naloxone can be in reversing overdoses and restoring breathing, fentanyl overdoses are often too extreme for the antidote to work. And naloxone is ultimately a Band-Aid to a broader, systemic addiction crisis across the city.

“In a place like the Bronx, where there was a long term underlying addiction issue, all of a sudden you saturate the area with cheap accessible heroin, and you’re going to start to see the spike,” the city’s special narcotics prosecutor, Bridget Brennan, said in an interview.

The recent surge of illegal heroin in the Bronx in many ways mirrors the surge of prescription painkillers that fueled the opioid epidemic in suburban and rural communities. In the Bronx, as elsewhere, accessibility is related to spikes in consumption and addiction.

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Jerome Sanchez working at a syringe exchange site. Four of the five New York City neighborhoods with the most opioid deaths are in the Bronx.

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Terrell Jones, left, and his colleagues at the New York Harm Reduction Educators hand out information about opioid deaths, offer free naloxone, and operate a syringe exchange program.

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A van operated by the Washington Heights Corner Project and New York Harm Reduction Educators provides training in the Bronx for the use of naloxone, a medication that can be used to reverse opioid overdoses.

An illegal prescription painkiller market also thrived in the Bronx. In one high-profile case, a physician who owned several medical clinics in the Bronx was convicted of illegally distributing millions of prescription painkillers between 2011 and 2014. (Oxycodone from that “pill mill” was likely distributed in the Bronx, northern parts of Manhattan and Brooklyn, officials have said.)

In Staten Island, the proliferation of prescription painkillers — often acquired illicitly through friends or dealers — led to an explosion in overdose deaths earlier this decade. Eventually Staten Island itself developed a market for heroin dealers.

“This group of people in Staten Island, who might have been put off by the illegality of heroin, they’re already addicted” to opioids, Ms. Brennan said, and were therefore more willing to try it. The ensuing rise in opioid-related deaths among white, middle-class men and women has helped change popular conceptions about who is susceptible to drug addiction.

“The impact plays out differently in different parts of the city, and different parts of the country, depending on the historical arch. But it’s got a huge impact wherever it hits. It’s so cheap, so accessible, so pure,” explained Ms. Brennan.

Given the significantly larger overall numbers of deaths in the Bronx, Dr. Chinazo Cunningham, a primary care physician affiliated with Montefiore Medical Center who has worked in the Bronx for decades, lamented that opioid-related deaths in the borough have not received more attention. She said the interest in Staten Island likely stems from its relatively new addiction crisis and the fact that white middle-class residents are being affected.

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The detritus of drug use: orange needle tips, blue syringe holders and tie-offs used for injecting heroin, at a site in Tremont Park.

“Really, the reason we care about the opioid epidemic is because it’s affecting populations that are white and affluent,” she said. “The way that we got to this is bittersweet, that this is what it has taken to shift the conversation to this way we’re talking about it.”

Dr. Cunningham, who is certified in addiction medicine, said it is important to balance medical data against stereotypes “portraying everyone in the Bronx as a drug user, or suggesting that all brown people are drug users.” Such assumptions are partially to blame for apathy in the overdose death crisis in the borough, she said.

In fact, in 2016, the highest rate of overdose deaths in the Bronx was among white residents, followed by Hispanics, and then African-Americans. Just 9 percent of Bronx residents are classified as non-Hispanic white.

City Hall has acknowledged the high death count in the Bronx, and has pledged a broad, citywide program to drive down fatalities. In March, Mayor Bill de Blasio chose Lincoln Hospital in the South Bronx to announce the new effort. Calling the 2016 fatalities “shocking” and “a wake up call,” Mr. de Blasio committed $38 million a year to an initiative aimed at reducing fatal drug overdoses by 35 percent over five years; he vowed to dramatically expand government-funded naloxone distribution throughout the city, while expanding treatment options and reducing the supply of opioids.

But community organizations on the ground and law enforcement are still struggling to curb the number of fentanyl- and heroin-related deaths.

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A former drug den known as “The Hole,” which was bulldozed by the city in May.

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Adriana Pericchi, director of harm reduction at the Washington Heights Corner Project, demonstrating how to test heroin for traces of fentanyl.

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Mike Bailey, an outreach worker, held up a needle discovered in a Bronx park. It’s bent, meaning that whoever used it may have been infected with a disease and didn’t want anyone else to use it, he said.

On a Wednesday afternoon in September, a plain gray van was parked across the street from Tremont Park, on the corner of Arthur and Tremont Avenues, and a blue tarp was erected next to it. The arrangement was a perhaps modest, but nonetheless crucial, outpost in the fight against opioid-related overdose deaths in the Bronx. Throughout the year, from this makeshift bureau and several others in the borough, Mr. Jones and his colleagues at New York Harm Reduction Educators hand out information about opioid deaths, offer free naloxone, and operate a syringe exchange program. (The program is funded largely through government grants.)

Adriana Pericchi sat in the blue tent, training passers-by how to administer naloxone to someone suffering an overdose. Slipping back and forth between conversational Spanish and English with a man seeking naloxone and fentanyl test strips, she moved methodically step-by-step, beginning with an overview of the physical symptoms of overdose: blue nails or lips, skin discoloration and shallow breaths. She jammed naloxone into a test dummy’s nose before playacting chest compressions and rescue breathing.

“First the breathing stops, then the brain, then the heart,” Ms. Pericchi reminded the man, a heroin user, who nodded along.

Later, sitting in a nearby McDonald’s, Ms. Pericchi opened up about the emotional toll felt by her colleagues at Washington Heights Corner Project and other organizations in the field.

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Culbert on her way home in a cab in the Bronx.

“A lot of us are doing our best, but it’s just not enough, it’s not enough,” she said. “You’re mourning for one particular person who you knew and loved. And really quickly that avalanches into mourning for the state of the city, the state, the country.”

Mr. Jones said the Bronx needs more resources to combat heroin deaths, and blamed racial politics for insufficient resources. He said policies from the War on Drugs have also made community members distrustful of the police. Speaking softly and slowly, he disclosed that he sold drugs during the 1980s to support his crack habit, eventually serving more than two years in prison.

Now, decades later, as he devotes himself to helping drug users who need help, Mr. Jones sees a continued double standard for Bronx residents, who are stripped of compassion and dignity amid an epidemic that has engendered sympathy and panic in other communities.

From his vantage point, the attitude toward the opioid deaths today is still influenced by racialized attitudes about the crack and heroin epidemics before.

“It’s just color. It’s like we’re part of a third-world country because we’re not part of the so-called privileged people,” Mr. Jones said. “I could be wrong, but I’m saying that it’s because of our color. It’s a big issue.”

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Culbert, left, passing a cigarette to a friend outside a syringe exchange site in the Bronx.